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HIV Among Transgender People

Terminology

Transgender is a term for people whose gender identity or expression is different from their sex assigned at birth. Gender identity refers to a person’s internal understanding of their own gender. Gender expression describes a person’s outward presentation of their gender (for example, how they dress). Transgender women describes people who were assigned the male sex at birth but identify as women. Transgender men describes people who were assigned the female sex at birth but identify as men.

The Numbers

A 2017 paper used meta-analysis and synthesized national surveys to estimate that 1 million adults in the United States are transgender.a

From 2009 to 2014, 2,351 transgender people were diagnosed with HIV in the United States.b

Eighty-four percent (1,974) were transgender women, 15% (361) were transgender men, and less than 1% (16) had another gender identity.

Around half of transgender people (43% [844] of transgender women; 54% [193] of transgender men) who received an HIV diagnosis from 2009 to 2014 lived in the South.

According to current estimates, around a quarter (22-28%) of transgender women are living with HIV, and more than half (an estimated 56%) of black/African American transgender women are living with HIV.

Among the 3 million HIV testing eventsc reported to CDC in 2015, the percentage of transgender people who received a new HIV diagnosis was more than 3 times the national average.

Nearly two thirds of transgender women and men surveyed by the Behavioral Risk Factor Surveillance System (BRFSS) in 2014 and 2015 from 28 jurisdictions reported never testing for HIV.

HIV Diagnoses Among Transgender People in the United States
by Race/Ethnicity, 2009-2014

Prevention Challenges

Multiple factors have put transgender people at risk for HIV infection and transmission, including multiple sexual partners, anal or vaginal sex without condoms or medicines to prevent HIV, injecting hormones or drugs with shared syringes and other drug paraphernalia, commercial sex work, mental health issues, incarceration, homelessness, unemployment, and high levels of substance misuse compared to the general population, as well as violence and lack of family support.

HIV behavioral interventions developed for other at-risk groups have been adapted for use with transgender people. However, the effectiveness of these interventions is understudied. According to a 2017 study, most existing interventions target behavior change among transgender women, with only one HIV prevention program evaluated for transgender men. Evidence-based multilevel interventions that address the structural, biomedical, and behavioral risks for HIV among transgender populations, including transgender men, are needed to address disparities in HIV prevalence.

Many transgender people face stigma, discrimination, social rejection, and exclusion that prevent them from fully participating in society, including accessing health care, education, employment, and housing. These factors affect the health and well-being of transgender people, placing them at increased risk for HIV.

Transgender women and men might not be sufficiently reached by current HIV testing measures. Tailoring HIV testing activities to overcome the unique barriers faced by transgender women and men might increase rates of testing among these populations.

Transgender men’s sexual health has not been well studied. Transgender men, particularly those who have sex with cisgender (persons whose sex assigned at birth is the same as their gender identity or expression) men, are at high risk for infection. Over half of transgender men with diagnosed HIV infection had no identified or reported risk. Additional research is needed to understand HIV risk behavior among transgender men, especially those who have sex with other men.

Insensitivity to transgender issues by health care providers can be a barrier for transgender people diagnosed with HIV and seeking quality treatment and care services. Few health care providers receive proper training or are knowledgeable about transgender health issues and their unique needs. This can lead to limited health care access and negative health care encounters.

Transgender women and men might not fully engage in medical care. In the United States, transgender and other gender minority youth are an at-risk group understudied in HIV prevention (e.g., PrEP) and HIV treatment. In one study, medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. In a study of transgender men living with HIV who were receiving medical care, 60% had maintained an undetectable viral load over the previous 12 months. A 2015 study found that 50.8% of transgender women who were receiving medical care had maintained an undetectable viral load over the previous 12 months. Sustaining an undetectable viral load through effective treatment is the best thing people living with HIV can do to stay healthy and protect their sexual partners. People living with HIV who sustain an undetectable viral load have effectively no risk of sexually transmitting HIV to an HIV-negative partner.

Transgender-specific data are limited. Some federal, state, and local agencies do not collect or have complete data on transgender individuals. Using the two-step data collection method of asking for sex assigned at birth and current gender identity can help increase the likelihood that transgender people are correctly identified in HIV surveillance programs. Accurate data on transgender status can lead to more effective public health actions.

What CDC Is Doing

CDC and its partners are pursuing a high-impact prevention approach to maximize the effectiveness of current HIV prevention methods among transgender people. Activities include:

In 2017, CDC awarded nearly $11 million per year for 5 years to 30 CBOs to provide HIV testing to young gay and bisexual men of color and transgender youth of color, with the goals of identifying undiagnosed HIV infections and linking those who have HIV to care and prevention services.

Partnering with Fenway Health to offer a free web-based CME/CEU program to address ways health care providers can help high-risk transgender people prevent HIV, improve care for transgender people living with HIV, and incorporate strategies to make clinical environments more welcoming to transgender patients.

Conducting a National HIV Behavioral Surveillance (NHBS) activity among transgender women that will use NHBS methods to conduct a behavioral interview and HIV testing among transgender women in 10 NHBS sites.

Providing support and technical assistance to health departments, CBOs, and providers to support interventions for transgender people (e.g., condom distribution, community mobilization, HIV testing, and coordinated referral networks and service integration).

Through its Capacity Building Assistance initiative, CDC is working with the Center of Excellence for Transgender Health to supportNational Transgender HIV Testing Day. This day promotes HIV testing, prevention, and treatment efforts among transgender people.

Developed Act Against AIDS communication materials to reach transgender people, including campaigns such as:

Doing It, which encourages all adults to get tested for HIV and know their status, and includes images and testimonial videos featuring transgender leaders.